FORT KENT, Maine — Northern Maine Medical Center violated federal standards when its chief executive ordered the alteration of a patient’s medical records, according to an investigation by the Maine Department of Health and Human Services.

NMMC CEO Peter Sirois ordered changes to the records of a patient who visited the emergency room in April 2007 following an incident of alleged domestic abuse, according to a statement of deficiency DHHS issued to the hospital after it conducted an inspection in March of this year.

DHHS previously investigated the matter in 2010. The case was reopened after an individual contacted the state in December 2013 claiming investigators were lied to and never followed up with the physicians involved, who had since left NMMC. The complainant offered supporting documentation, including a sworn deposition by Sirois and an affidavit signed by an ER doctor, which contradicted Sirois’ version of events.

The complainant’s name was redacted in documents obtained by the Bangor Daily News through a Freedom of Access Act request. The story was first reported by the Fiddlehead Focus, a community news website in Fort Kent.

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The patient, who was pregnant at the time, visited the hospital ER after Fort Kent police arrested her husband, an NMMC physician, on a domestic violence charge, according to the significantly redacted investigation documents and notes by staff in DHHS’ licensing and regulatory division.

The investigation centered on whether a subsequent meeting between the patient and a hospital psychiatrist constituted a formal consultation, as well as the handling of records documenting that meeting.

ER physician Dr. Paul Strait ordered a psychiatric consultation for the patient, according to his affidavit.

Sirois, who was the hospital’s chief operating officer at the time of the incident, described the interaction differently in a deposition, labeling it a friendly visit.

A formal consultation would be documented in a patient’s medical records while a social visit wouldn’t.

The individual who complained to regulators provided Strait’s affidavit, dated Nov. 17, 2013, to DHHS in January, writing the document was part of a “tangentially related matter.” The complainant also supplied transcripts of Sirois’ June 4, 2013, deposition and a Dec. 6, 2013, deposition by the involved hospital psychiatrist, both provided as part of the same related matter.

The hospital psychiatrist called to the ER to conduct the consultation knew the alleged abuser. Before starting the consultation, the psychiatrist realized the patient was the wife of her ex-husband, who abused the psychiatrist and threatened to kill her multiple times, she said in her Dec. 6, 2013, deposition.

The patient’s name was redacted from the investigative documents. The Bangor Daily News is not naming the psychiatrist because she was an alleged victim of domestic abuse.

The psychiatrist called Sirois, stating she felt uncomfortable meeting with the patient and asked if she could contact the medical director of the psychiatry department to come in and handle the consultation instead. Sirois said it was too late to call the medical director and instructed her to “try to be professional,” she said in the deposition.

Sirois was aware of her history with the alleged abuser, the psychiatrist said.

The psychiatrist conducted the consultation and later opposed the removal of her report from the patient’s records, she said.

In his deposition, Sirois acknowledged ordering documentation of the visit be purged from the patient’s file. He said staff told him a consultation was never ordered, so he reasoned documentation of the meeting with the psychiatrist didn’t need to be included in her records.

The patient viewed the psychiatrist’s notes after the visit and was upset by the diagnosis. The patient called Sirois and asked him to have the documentation removed, saying she met with the psychiatrist in hopes of being consoled by someone who had been abused by the same man, Sirois said in his deposition.

Sirois claimed he told the psychiatrist to meet with the patient only after she said the psychiatry medical director couldn’t be reached.

The psychiatrist resigned from NMMC shortly after the incident. The alleged abuser also no longer works for the hospital.

The DHHS investigation did not explore the appropriateness of the psychiatrist meeting with a patient with whom she shared a personal connection.

The psychiatrist and Strait, the ER physician, said they were never interviewed by state investigators until 2014. At that time, Strait said Sirois visited him shortly after the incident to tell him it was just a “friendly visit.” Strait said that characterization was “absolutely not true.”

In this year’s investigation, Sirois told state investigators the documentation was removed from the patient’s medical record but kept separately “in case of some sort of legal action.”

DHHS investigators inspected the patient’s records, finding no reference to the existence of the missing documentation, according to the statement of deficiencies. The file was eventually uncovered in the back of a drawer, after an NMMC employee responsible for health information needed to call her predecessor in the position to determine its location.

NMMC had no policy or procedure explaining the removal of documentation from patient medical records, storage of documentation outside of medical records or methods for documenting the removal of such information or retrieving it, DHHS noted. The hospital failed to “ensure the confidentiality of the entire patient’s medical record,” state investigators noted.

The hospital submitted a plan of correction and in a May letter to DHHS wrote the hospital “sequestered” portions of some medical records, pertaining to open litigation, in a separate location. The issue became obsolete with the advent of electronic medical records, the letter states.

“NMMC no longer sequesters records and all records that were present in the safe have been placed back into circulation,” the letter reads. “NMMC does not intend on continuing this practice.”

No sanctions or fines were levied against the hospital, Norman Fournier, chairman of NMMC’s board of trustees, said.

The hospital welcomed the DHHS investigators and implemented the required records policy, he said.

“The matter was resolved very satisfactorily, and we’ve moved on. … We as the board of trustees have the utmost confidence in our CEO’s integrity,” Fournier said.

If you or someone you know is experiencing domestic violence and would like to talk with an advocate, call 866-834-4357, TRS 800-787-3224. This free, confidential service is available 24/7 and is accessible from anywhere in Maine.